Pupils Name: ................................................................... Date of Birth: ............................ CHI Number: ...............................................

Todays Date: ........................... Name of person completing questionnaire: ....................................................... Class: .....................
Head Teacher: .......................................................... Class Teacher/Year Head: ..........................................................................................
Please indicate if pupil has any of the following (circle):

Group Educational Plan / IEP / IP / CSP

These questions are designed for children from nursery to secondary school.
Please circle only one of the four choices, answer each question as fully as possible and
select a response for each question

ROUTINE & ROLE

None Some Most

of the of the of the
time
time
time

All
of the
time

a. Your pupil organises routines (e.g. organising belongings, organising homework) ...................................... 1

b. Your pupil copes with changes in his/her routine .................................................................................................. 1

c. Your pupil copes with a variety of activities within their daily routine
(e.g. nursery/classroom activities, PE, after school clubs) ...................................................................................................... 1

d. Your pupil understands their responsibilities (e.g. running errands, responsibility for
tidying/managing nursery/classroom resources, completing homework) ........................................................ 1

e. Your pupil manages multiple responsibilities within a day (e.g. running errands,
responsibility for tidying/managing nursery/classroom resources,
completing tasks and homework) ............................................................................................................................... 1

a. Your pupil is confident in their abilities ..................................................................................................................... 1

b. Your pupil enjoys school activities (e.g. drawing/handwriting, school work, outdoor play /PE) ............... 1

c. Your pupil seems satisfied with his/her performance in activities (e.g. drawing/handwriting
school work, outdoor play or P.E.)............................................................................................................................. 1

d. Your pupil can tell you what he/she wants to get better at (e.g. drawing/handwriting
school work, outdoor play or P.E.)............................................................................................................................. 1

e. Your pupil keeps trying despite challenges doing activities (e.g. drawing/handwriting
school work, outdoor play or P.E.)............................................................................................................................. 1

a. Your pupil plays/interacts well with others .................................................................................................................................. 1

b. Your pupil is chatty/sociable and talks with his/her friends ................................................................................. 1

c. Your pupil speaks clearly when with others (e.g. with adults or when playing/working
with classmates/friends) ................................................................................................................................................ 1

d. Your pupil demonstrates an understanding of others feelings (e.g. with adults/classmates or friends) ........ 1

e. Your pupil can ask for the support he/she needs ...................................................................................................................... 1

CONFIDENCE

SOCIAL SKILLS

ORGANISATION SKILLS

None Some Most

of the of the of the
time
time
time

All
of the
time

a. Your pupil organises and uses objects to complete activities

(e.g. nursery/classroom activities/homework) ........................................................................................................ 1

b. Your pupil maintains concentration throughout activities ................................................................................. 1

c. Your pupil works out problems if he/she gets stuck on a task........................................................................... 1

d. Your pupil follows through instructions to complete activities .......................................................................................... 1

e. Your pupil completes the steps of an activity in the right order........................................................................ 1

a. Your pupil is able to navigate his/her way around their physical environment when there
is plenty of space (e.g. not bumping into things, spilling, or knocking things over) ...................................... 1

b. Your school environment has opportunities to support your pupil to do activities

(e.g. playground activities, clubs, after school activities) .................................................................................... 1

c. At school, your pupil has access to the things to help them take part in activities
(e.g. looped scissors, chunky pencils, ICT) .............................................................................................................. 1

d. School staff are available to support your pupil to take part in activities (e.g. playground/
classroom activities, after school clubs) ...................................................................................................................... 1

e. The school environment supports your pupil to take part in classroom activities
(e.g. quiet spaces, small/large group work, individual working space) .............................................................................. 1

a. Your pupil completes activities without being clumsy (e.g. avoids spilling fluids or
banging/breaking objects during activities) ............................................................................................................... 1

b. Your pupil is able to complete daily activities without losing their balance or stumbling
(e.g. playing outside) ........................................................................................................................................................ 1

c. Your pupil is able to grip objects effectively when doing activities (e.g. grips pencil when
doing drawing/writing, grips containers when opening them) ........................................................................... 1

d. Your pupil has adequate physical dexterity to complete activities (e.g. when tying shoelaces,
fastening buttons/zips, physically moving their body to catch a ball) ..................................................................... 1

e. Your pupil completes activities without physical fatigue

(e.g. football, scooter/bike, swimming) ..................................................................................................................... 1

a. Your pupil is calm and happy to be separated from parents/carers for short periods of time ................ 1

b. Your pupil seems confident and self assured ........................................................................................................... 1

c. Your pupil is undaunted by, and willing to tackle new experiences .................................................................................. 1

d. Your pupil is appropriately sensitive to things in their environment (e.g. can tolerate extremes
of temperature, can block out noise, unfussy diet, likes most tastes or textures) ............................................ 1

e. Your pupils level of alertness is about right (e.g. interested in activities, can get going and
is motivated, energetic and does not complain of being overly tired) .............................................................. 1

ENVIRONMENT

f.

Your pupil is able to complete activities in the usual/accepted way (e.g. can do shoelaces
instead of using Velcro, team sports without changing rules) ............................................................................ 1

PHYSICAL SKILLS

EMOTIONS & SENSATIONS

Thank you for your help. Please return the questionnaire in the enclosed envelope